Asymptomatic HTN

[DocEspana]

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btw in february or march of this year ACEP changed the recommendations in a really subtle way. They previously used to say that you didn't need to start any new meds, just pass it off the PCP (and if you read the FULL report a lot of that is that since blood work isnt necessary on these patients but blood work IS needed to start any med except ccbs, just dont start meds so you dont have to draw blood). Now they say that we *should* start meds and/or increase current dosages if the reason is not noncompliance or just pain/anxiousness. They still make it very clear that there is no goal BP or any "dangerous" BP to act differently over. They are just making day zero of new treatment be the ED visit.

I have no problem with the recommendations.

I have a problem with them taking down (and completely wiping the internet of) their old recommendations which had SUCH a good patient-friendly summary of the "dont test, don't treat, don't worry' mantra. Now they only have the overly-dense medical version of the new guidelines.

 

[DocEspana]

You guys actually bother trying to educate other doctors on why it's pointless to send them in?

One of our PCP's sent in a woman who was ~200/100. No symptoms but apparently there were EKG changes. I looked at them and they were subtle STD or even non-existent. One of those kinds that you can barely see. I tried letting the PCP know there isn't much for us to do, and even said our national guidelines write to not treat and to let outpatient doctors treat. She was an outpatient doctor and sent her in anyway.

I don't even know if it's worth it these days.

I'm sure everyone else has said it, but you can't educate the PCPs. Not that its impossible but that 51% of those referrals are actually coming from their triage nurse, waiting room receptionist, or answering service, not the PCP. 44% are coming from physicians who "have been practicing this way for years and nothing bad has happened yet" and are closed to the idea of changing their patterns. About 5% actually sent them over for some other reason but the patient is too fixated on the BP to even know why they got sent.

 

[thegenius]

btw in february or march of this year ACEP changed the recommendations in a really subtle way. They previously used to say that you didn't need to start any new meds, just pass it off the PCP (and if you read the FULL report a lot of that is that since blood work isnt necessary on these patients but blood work IS needed to start any med except ccbs, just dont start meds so you dont have to draw blood). Now they say that we *should* start meds and/or increase current dosages if the reason is not noncompliance or just pain/anxiousness. They still make it very clear that there is no goal BP or any "dangerous" BP to act differently over. They are just making day zero of new treatment be the ED visit.

I have no problem with the recommendations.

I have a problem with them taking down (and completely wiping the internet of) their old recommendations which had SUCH a good patient-friendly summary of the "dont test, don't treat, don't worry' mantra. Now they only have the overly-dense medical version of the new guidelines.

You referring to this?

https://www.acep.org/siteassets/sites/acep/media/clinical-policies/final-cp-pdfs/asxhypertension-cp.pdf

 

[DocEspana]

You referring to this?

https://www.acep.org/siteassets/sites/acep/media/clinical-policies/final-cp-pdfs/asxhypertension-cp.pdf

Yup. The old page where they had a similar formal paper AND a simplified "two questions you need to know" based on the 2013 recommendations is gone. Which I understand based on them having new recommendations. But I really wish they left the old page because that "two questions you need to know" would need only the slightest modification to still be accurate and was so useful for reassuring patients that their asymptomatic htn is fine.

 

[southerndoc]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

 

[VA Hopeful Dr]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

So you're giving them 6 months of medication when you discharge them?

 

[WhatJobDoIPick]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

I give a month of Losartan. No reason not to.

 

[turkeyjerky]

So you're giving them 6 months of medication when you discharge them?

30 days of meds, but tell pt to check their BP 3x per day and “only use ‘em if you need ‘em!”

 

[WhatJobDoIPick]

30 days of meds, but tell pt to check their BP 3x per day and “only use ‘em if you need ‘em!”

I send home with radial art line in place for real time monitoring

 

[BoardingDoc]

I send home with radial art line in place for real time monitoring

Pfft. Baby. I just throw a 20cc bottle of hydralazine in a bag with a bunch of syringes and needles and send them on their way. People are smart. They'll figure it out.

 

[RustedFox]

Pfft. Baby. I just throw a 20cc bottle of hydralazine in a bag with a bunch of syringes and needles and send them on their way. People are smart. They'll figure it out.

Pfft. Baby. I prescribe PRE-arrival meds to RAISE their asymptomatic HTN for the gainz.

 

[BoardingDoc]

 

[RustedFox]

View attachment 408824

This got me to laugh hard in the middle of the gym.

 

[southerndoc]

So you're giving them 6 months of medication when you discharge them?

Yes

 

[DocEspana]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

which is why ACEP changed their recommendations from "accidentally overtreating is a real thing, so maybe think twice before starting new meds" to "just start them on something if they have nothing."

My (huge, flashing, and flaming) concern is that htn is not supposed to be diagnosable by the standard criteria on a single elevated measurement or on those who are sick/in pain for the most part. So we are really *still* running afoul of the concern ACEP had from 2013 until earlier this year - that we might be starting a daily medication for a temporary BP rise and leading to iatrogenic hypotension. But I do trust, especially after reading their reasoning on it, that starting meds is more benefit than harm for most people and assume we can use some common sense to feel out where the patterns for 'this is temporary' vs 'this is htn' exist.

 

[thegenius]

which is why ACEP changed their recommendations from "accidentally overtreating is a real thing, so maybe think twice before starting new meds" to "just start them on something if they have nothing."

My (huge, flashing, and flaming) concern is that htn is not supposed to be diagnosable by the standard criteria on a single elevated measurement or on those who are sick/in pain for the most part. So we are really *still* running afoul of the concern ACEP had from 2013 until earlier this year - that we might be starting a daily medication for a temporary BP rise and leading to iatrogenic hypertension. But I do trust, especially after reading their reasoning on it, that starting meds is more benefit than harm for most people and assume we can use some common sense to feel out where the patterns for 'this is temporary' vs 'this is htn' exist.

I'm not entirely opposed to starting or adjusting their meds. But for many of the reasons you write above I tend not to do it. It's a case-by-case basis and I suspect I do it less than the average ER doc. I certainly don't give an Rx for 6 months. That may not even be standard of care in the PCP office if you are starting someone on HTN medicine for the first time.

Just yesterday UC sent in an asymptomatic woman who was 200/100. They had the good sense to give clonidine 0.1 mg (should have been 0.2 mg) and wait like 30 minutes, and the BP went down to 185. After my history I restarted her two BP meds she has been on in the past that she stopped taking.

 

[southerndoc]

which is why ACEP changed their recommendations from "accidentally overtreating is a real thing, so maybe think twice before starting new meds" to "just start them on something if they have nothing."

My (huge, flashing, and flaming) concern is that htn is not supposed to be diagnosable by the standard criteria on a single elevated measurement or on those who are sick/in pain for the most part. So we are really *still* running afoul of the concern ACEP had from 2013 until earlier this year - that we might be starting a daily medication for a temporary BP rise and leading to iatrogenic hypotension. But I do trust, especially after reading their reasoning on it, that starting meds is more benefit than harm for most people and assume we can use some common sense to feel out where the patterns for 'this is temporary' vs 'this is htn' exist.

I usually prescribe, but tell them to take their BP at home or with a friend's machine. If it remains >140/90, then start the medication.

 

[DocEspana]

I usually prescribe, but tell them to take their BP at home or with a friend's machine. If it remains >140/90, then start the medication.

In the last year, I moved from an inner city, largely Haitian, community to a a suburban largely affluent community.

The adjustment has been rough. Going from blood pressure values that seem incompatible with nephron survival being their everyday functional status, to people checking their BP q15 minutes for 6 hours and wondering why they went from 131/65 (that's high for me, doc) to 175/66 with each check is an adjustment.

I wish I could prescribe the former new kidneys and the latter new brains.

 

[Zebra Hunter]

I'm not entirely opposed to starting or adjusting their meds. But for many of the reasons you write above I tend not to do it. It's a case-by-case basis and I suspect I do it less than the average ER doc. I certainly don't give an Rx for 6 months. That may not even be standard of care in the PCP office if you are starting someone on HTN medicine for the first time.

Just yesterday UC sent in an asymptomatic woman who was 200/100. They had the good sense to give clonidine 0.1 mg (should have been 0.2 mg) and wait like 30 minutes, and the BP went down to 185. After my history I restarted her two BP meds she has been on in the past that she stopped taking.

“Good sense”. People need to stop giving clonidine to patients with hypertension. It’s essentially never appropriate and drives me up a wall when I see my anxiety, hypertensive patients on PRN clonidine. Its duration of action is ~4 hours and can potentially cause rebound hypertension.

 

[RustedFox]

“Good sense”. People need to stop giving clonidine to patients with hypertension. It’s essentially never appropriate and drives me up a wall when I see my anxiety, hypertensive patients on PRN clonidine. Its duration of action is ~4 hours and can potentially cause rebound hypertension.

I'm not sure I believe the four-hour duration of action. I take it for sleep. 0.3, and my muscles just "quit" and really won't work the next day at the gym. I learned not to do that if I want to lift.

 

[DocEspana]

“Good sense”. People need to stop giving clonidine to patients with hypertension. It’s essentially never appropriate and drives me up a wall when I see my anxiety, hypertensive patients on PRN clonidine. Its duration of action is ~4 hours and can potentially cause rebound hypertension.

I thought the duration of action was much longer, like much, much longer. It gives a decent decrease in BP in that 4-Hour window but (unless I'm misremembering something) you actually measure toxicity and total exposure in how much you've taken over the last 36 hours because the half-life is just an eternity and seemingly appropriate amounts can lead to toxicity the next day if you repeatedly dose based on BP rather than "total amount ingested".

 

[VA Hopeful Dr]

Yes

Well then, fair enough.

Make sure it's something that doesn't need reasonably close lab follow up.

 

[southerndoc]

In the last year, I moved from an inner city, largely Haitian, community to a a suburban largely affluent community.

The adjustment has been rough. Going from blood pressure values that seem incompatible with nephron survival being their everyday functional status, to people checking their BP q15 minutes for 6 hours and wondering why they went from 131/65 (that's high for me, doc) to 175/66 with each check is an adjustment.

I wish I could prescribe the former new kidneys and the latter new brains.

I'm sure if the Apple Watch that is released next week has built-in BP monitoring, our number of asymptomatic hypertensive patients is going to increase.

 

[southerndoc]

Well then, fair enough.

Make sure it's something that doesn't need reasonably close lab follow up.

Usually ARB or amlodipine.

 

[thegenius]

“Good sense”. People need to stop giving clonidine to patients with hypertension. It’s essentially never appropriate and drives me up a wall when I see my anxiety, hypertensive patients on PRN clonidine. Its duration of action is ~4 hours and can potentially cause rebound hypertension.

Not a single one time dose. I think it's perfect for single use around the histrionics of elevated BPs.
I do think it's a terrible long term HTN med though.

 

[Brigade4Radiant]

Rebound hypertension is for 900mcg of clonidine and taking it for weeks and then abruptly taking it out.

Clonidine 0.1 is useful for getting the nurses and patients to calm down. It’s not a good long term medicine

I do give patients losartan-hctz if they want something I usually do two classes since in all honesty they will get therapeutic inertia in Trying to treat their bp

 

[VA Hopeful Dr]

Usually ARB or amlodipine.

Probably fine but technically you should get follow up labs with ARBs.

 

[southerndoc]

Probably fine but technically you should get follow up labs with ARBs.

I agree, but 6 months is decent follow-up. I don't see my PCP every 3 months for labs for my telmisartan.

 

[VA Hopeful Dr]

I agree, but 6 months is decent follow-up. I don't see my PCP every 3 months for labs for my telmisartan.

Nor do I require that for my patients, but official guidelines are check a BMP 2-4 weeks after starting ACE/ARB

 

[southerndoc]

Nor do I require that for my patients, but official guidelines are check a BMP 2-4 weeks after starting ACE/ARB

I don't think my PCP followed that guideline. LOL

 

[VA Hopeful Dr]

I don't think my PCP followed that guideline. LOL

I don't either most of the time, not sure many of us do.

 

[RustedFox]

I thought the duration of action was much longer, like much, much longer. It gives a decent decrease in BP in that 4-Hour window but (unless I'm misremembering something) you actually measure toxicity and total exposure in how much you've taken over the last 36 hours because the half-life is just an eternity and seemingly appropriate amounts can lead to toxicity the next day if you repeatedly dose based on BP rather than "total amount ingested".

Oral half life is 12-16 hours . I had to look it up because I took 0.2mg late yesterday to pass TFO after a plane trip home and now the "poisoned" status effect animation (like in a video game) is above my head all day today.

 

[DocEspana]

Not a single one time dose. I think it's perfect for single use around the histrionics of elevated BPs.
I do think it's a terrible long term HTN med though.

Rebound hypertension is for 900mcg of clonidine and taking it for weeks and then abruptly taking it out.

Clonidine 0.1 is useful for getting the nurses and patients to calm down. It’s not a good long term medicine

I do give patients losartan-hctz if they want something I usually do two classes since in all honesty they will get therapeutic inertia in Trying to treat their bp

Just going to sort of address both of you at once. You're probably right, but having seen what happens if you give too much clonidine (aka you need to admit the person for 1-2 days for hypotension resistant to IV fluids and most pressors) I just stay the hell away from it. I get a lot of patients in Miami who get a dose of it at their PCP or an urgent care center and then get sent to me. And I honestly never have seen anyone suffer overdose toxicity with that one dose, but in New York City it was not uncommon to have a PCP give 0.2 followed by 0.1 or even sometimes 0.2 twice and then send them over *nominally* for recalcitrant hypertension only for them to be rocking into the ER 87/42 because it's been 60 and 120 minutes since their dosing due to ambulance time.

Because of that I completely avoid clonidine for hypertension (I'll use it for opiate withdrawal, even though that's beginning to fall out of favor) unless the complaint is literally asymptomatic hypertension on a patient who's supposed to be taking clonidine but isn't and it's a holiday weekend so they can't go to the pharmacy anytime soon to pick up their home meds.

Oral half life is 12-16 hours . I had to look it up because I took 0.2mg late yesterday to pass TFO after a plane trip home and now the "poisoned" status effect animation (like in a video game) is above my head all day today.

 

[thegenius]

Oral half life is 12-16 hours . I had to look it up because I took 0.2mg late yesterday to pass TFO after a plane trip home and now the "poisoned" status effect animation (like in a video game) is above my head all day today.

what does that mean?

 

[RustedFox]

what does that mean?

"pass the **** out".

I got home after a long day of travel and my brain was doing that thing it does where it plays sound clips from video games that I remember from the early 90s, then thinks about friends I had in elementary school before we moved, then remembers about how I shouldn't have traded the "40/40 Club" Rickey Henderson card to the one friend only for him to not take care of it, followed by trying to remember what data I was supposed to get to my accountant next week who reminds me of the host of MTV's "Remote Control", then...


0.2mg Clonidine. Stop it, brain.

 

[pkwraith]

US FDA clears Apple Watch hypertension feature

US FDA clears Apple Watch hypertension feature

The U.S. Food and Drug Administration (FDA) has cleared Apple to roll out a hypertension detection feature on some of its smartwatches, the health regulator said in a statement late on Friday.

www.reuters.com

Looking forward to this...

 

[southerndoc]

US FDA clears Apple Watch hypertension feature

US FDA clears Apple Watch hypertension feature

The U.S. Food and Drug Administration (FDA) has cleared Apple to roll out a hypertension detection feature on some of its smartwatches, the health regulator said in a statement late on Friday.

www.reuters.com

Looking forward to this...

Increased patient volume in the ER at 2 am... 😀

 

[CopaceticOne]

Increased patient volume in the ER at 2 am... 😀

And right after their morning caffeine binge